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PROOF OF INSURANCE (2022 - 2022) CLOSEDACCO " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D D/YYYY) Ill 1 07/02/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Rhonda Scow, CISR NAME: Landscape Contractors Insurance Services HONE. (559) 650-3555 q/c, (559) 650-3558 Ext : No): Insurance Services, Inc. E-MAIL rscow@lcisinc.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 1835 N. Fine Avenue INSURERA: Clear Blue Insurance Company 28860 Fresno CA 93727 INSURED INSURER B Oliver Holt Landscape INSURER C : 8611 Amestoy Avenue INSURER D : INSURER E : Sherwood Forest CA 91325 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 Pkg &Auto REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FX OCCUR PREM SDA AGESOEa occurrrence $ 100'000 MED EXP (Any one person) $ 5,000 X $1,000 Pd Ded PERSONAL &ADV INJURY $ 1,000,000 A Y LC01-00698-2102 07/16/2021 07/16/2022 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X JECT LOC PRODUCTS-COMP/OPAGG $POLICY❑PRO 2,000,000 Employee Benefits $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS LC01-00698-2102 07/16/2021 07/16/2022 BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED �/ NON -OWNED AUTOS ONLY X AUTOS ONLY Medical payments $ 5,000 UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N PER OE STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE El OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All landscape operations performed by or on behalf of the named insured. Blanket Additional insured per attached DBLC0434005012519 City of El Segundo and its officers, elected officials, and employees (Excluding Professional Liability) are named as additional insured per attached endorsement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street Room 5 AUTHORIZED REPRESENTATIVE ElSegundo CA 90245-3813 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. The following is added to Paragraph 2. In SECTION II - WHO IS AN INSURED: Any person or organization you are required by written contract or agreement to name as an additional insured subject to the following: Any such person or organization must be approved in writing by us as an additional insured. Coverage for such person or organization will begin on the date of our approval. a. No such person or organization is an additional insured for your acts, errors or omissions if such acts, errors or omissions are not also covered under such person or organization's liability insurance. b. No such person or organization is an additional insured for "bodily injury" or "property damage" for acts errors or omissions of any additional insured. B. With respect to the insurance afforded to the additional insureds under Paragraph A. above, the following is added to SECTION III - LIMITS OF INSURANCE: The most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement does not increase the applicable Limits of Insurance shown in the Declarations. C. With respect to the insurance afforded to the additional insureds under Paragraph A. above, Paragraph I. Damage to Your Work in Paragraph 2. Exclusions of COVERAGE A - BODILIY INJURY AND PROPERTY DAMAGE LIABILITY in SECTION I- COVERAGES is replaced by the following This insurance does not apply to: I. Damage to Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products - completed operations hazard". D. With respect to the insurance afforded to the additional insureds under Paragraph A, above, the following is added to Paragraph 4. Other Insurance in SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS: Page 1 of 2 DB LC 0434-005 0125 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission This insurance is primary if required by the contract or agreement. If there is no such requirement, this insurance will be excess and paragraph b. Excess Insurance applies. E. With respect to the insurance afforded to the additional insureds under Paragraph A. above, the following is added to Paragraph 8. Transfer of Rights of Recovery Against Others to Us, in SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS However, we will waive our rights to recover against any additional insured for payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under the contract or agreement and included in the "products completed operations hazard" if such waiver is required by the contract or agreement. All other terms and conditions of this Policy remain unchanged. Policy Number: LC01-00698-2102 Named Insured: Oliver Holt Landscape This endorsement is effective on the inception date of this policy unless otherwise stated herein. Endorsement Effective Date: 10/20/2021 Page 2 of 2 DB LC 0434-005 0125 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission ACCO " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D D/YYYY) ill 1 10/29/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Rhonda Scow, CISR NAME: Landscape Contractors (Lic#0755906) (559) 650-3555 q/c, (559) 650-3558 �CONN. Ext : No): Insurance Services, Inc. E-MAIL rscow@lcisinc.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 1835 N. Fine Avenue INSURERA: State Compensation Insurance Fund 35076 Fresno CA 93727 INSURED INSURER B Oliver Holt Landscape INSURER C : 8611 Amestoy Avenue INSURER D : INSURER E : Sherwood Forest CA 91325 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 WC REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS -MADE OCCUR (Ea occurrence) $ -PREMISES MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION P` AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A Y 9129706-2021 04/01/2021 04/01/2022 /� STATUTE EORH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE- EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All landscape operations performed by or on behalf of the named insured. "" WC Waiver of Subrogation on Order""" Waiver of Subrogation in favor of City of El Segundo and its officers, elected officials, and employees (Excluding Professional Liability) "This revises certificate dated 3/29/2021" ***WC Waiver attached 11/3/2021** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street Room 5 AUTHORIZED REPRESENTATIVE ElSegundo CA 90245-3813 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT BROKER COPY COMPENSATION WAIVER OF SUBROGATION 9129706-21 FUND RENEWAL NE HOME OFFICE 1-53-82-86 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE NOVEMBER 2, 2021 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING APR I L 1, 2022 AT 12.01 A.M. PACIFIC STANDARD TIME OLIVER HOLT LANDSCAPE 8611 AMESTOY AVE SHERWOOD FOREST, CA 91325 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, OLIVER HOLT LANDSCAPE IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: NOVEMBER 4, 2�0 21 2570 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217